Provider Demographics
NPI:1295735405
Name:ROBERTS, AMY DENISE (OT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:DENISE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:DENISE
Other - Last Name:PENDERGRAFT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3817 W DALLAS ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-4539
Mailing Address - Country:US
Mailing Address - Phone:918-845-1200
Mailing Address - Fax:918-398-9314
Practice Address - Street 1:3817 W DALLAS ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-4539
Practice Address - Country:US
Practice Address - Phone:918-845-1200
Practice Address - Fax:918-398-9314
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOT 800225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100639960BMedicaid